Evidence based Evidence based management – Pyogenic management – Pyogenic

meningitis in childrenmeningitis in children

Dr.T.KanimozhiDr.T.KanimozhiJunior resident Junior resident

Dept of pediatricsDept of pediatricsJIPMERJIPMER

IntroductionIntroduction

Definition: Inflammation of meninges – Definition: Inflammation of meninges – pia, arachnoid and subarachnoid pia, arachnoid and subarachnoid space space

Medical emergencyMedical emergency Important cause of mortality and Important cause of mortality and

morbidity world widemorbidity world wide Mortality of untreated bacterial Mortality of untreated bacterial

meningitis- 100% ;even among meningitis- 100% ;even among treated 16- 32% in Indiatreated 16- 32% in India

Incidence Incidence

Commonest in infancyCommonest in infancy

95% cases 1month- 5yrs95% cases 1month- 5yrs

Males > femalesMales > females

EpidemiologyEpidemiology After the introduction of After the introduction of

the the Haemophilus influenzaeHaemophilus influenzae type b (Hib)  type b (Hib) and pneumococcal conjugate vaccines, and pneumococcal conjugate vaccines, incidence of bacterial meningitis incidence of bacterial meningitis declined in all age groups except declined in all age groups except children younger than two months children younger than two months

The median age shifted from <5 years The median age shifted from <5 years to 42 years to 42 years

The peak incidence continues to occur The peak incidence continues to occur in children younger than two monthsin children younger than two months

Etiology Etiology Age Causative organism

0- 3 months Group B streptococcus, gram negative bacilli, staph. Aureus, listeria monocytogenes

3months – 3 yrs N.meningitidis, H.influenza, S.pneumoniae

> 3 yrs S.pneumoniae, N.meningitidis

Precipitating factors Causative organisms

Defects of complement system (C5-8) and properdin

Meningococcus

Splenic dysfunction H.Influenza B, pneumococcus

T-lymphocyte defects Listeria monocytogenes

CSF leaks and cochlear implants

Pneumococcus

CSF shunts CONS, Staph. Aureus

Lumbosacral dermal sinus and meningocoele

Staph. Aureus, gram negative enteric bacilli

Bacterial profile in a tertiary Bacterial profile in a tertiary care centre in south india care centre in south india

( 10 yr retrospective study)( 10 yr retrospective study)Gram positive Gram negative

S. Pneumoniae (mc) K. Pneumoniae (mc)

S.pyogenes P.aeruginosa

CONS Acinetobacter

S.aureus E.coli

Enterococci sps H.influenza

Enterobacter sps

Journal of Scientific and Innovative Research Journal of Scientific and Innovative Research 2013 2013

Clinical featuresClinical features

depend on the age of the patient and depend on the age of the patient and duration of diseaseduration of disease

Onset of acute BM has two formsOnset of acute BM has two forms

1. sudden onset- rapidly progressive 1. sudden onset- rapidly progressive shock, purpura , DIC, reduced level of shock, purpura , DIC, reduced level of consciousness leading to death in consciousness leading to death in 24hrs24hrs

2.Common form with Non specific 2.Common form with Non specific findings - fever(84%) findings - fever(84%)

headache(76%)headache(76%)

vomiting(70%)vomiting(70%)

anorexia(19%) anorexia(19%)

poor feedingpoor feeding

symptoms of URTIsymptoms of URTI

myalgia , arthralgia myalgia , arthralgia

petechiae , rash etcpetechiae , rash etc

Alteration in mental status (5%)Alteration in mental status (5%) Seizures (20 -30%)Seizures (20 -30%) Bulging fontanelle (esp in neonates)Bulging fontanelle (esp in neonates) Signs of meningeal irritation(59%) - Signs of meningeal irritation(59%) -

neck stiffness(65%), kernigs neck stiffness(65%), kernigs sign(27%) and brudzinski sign(51%)sign(27%) and brudzinski sign(51%)

Focal neurological deficitFocal neurological deficit

Classical signs often absent in infants Classical signs often absent in infants with meningitiswith meningitis

Hence, high index of suspicion is Hence, high index of suspicion is necessarynecessary

Initial managementInitial management

Resuscitation Resuscitation

AAirway & irway & BBreathing- give supplemental reathing- give supplemental oxygen and intubate ,if necessaryoxygen and intubate ,if necessary

CCirculation – treat shock with rapid irculation – treat shock with rapid fluid infusion and vasopressorsfluid infusion and vasopressors

DDisability-if signs of cerebral edema + isability-if signs of cerebral edema + -give mannitol-give mannitol

EExposure- rash- meningococcal xposure- rash- meningococcal sepsis; regulation of temperature is sepsis; regulation of temperature is importantimportant

FFluids- fluid restriction not necessary luids- fluid restriction not necessary unlesss there is SIADH or raised ICP unlesss there is SIADH or raised ICP

GGlucose – checked early and lucose – checked early and corrected if necessarycorrected if necessary

SSeizures: IV diazepam or lorazepam eizures: IV diazepam or lorazepam f/b phenytoin (15-20mg/kg loading; f/b phenytoin (15-20mg/kg loading; 5mg/kg/day maintainence) to reduce 5mg/kg/day maintainence) to reduce the likelyhood of recurrencethe likelyhood of recurrence

Management algorithmManagement algorithm

IDSA guidelines.2004IDSA guidelines.2004

Routine investigationsRoutine investigations CBC :Neutrophilia s/o bacterial infection CBC :Neutrophilia s/o bacterial infection Serum glucose: Often low; allows Serum glucose: Often low; allows

interpretation of CSF glucoseinterpretation of CSF glucose Electrolytes, urea, and creatinine :To assess Electrolytes, urea, and creatinine :To assess

for complications and fluid managementfor complications and fluid management Coagulation studies: To assess for Coagulation studies: To assess for

complicationscomplications Blood cultures : Positive in 40–90% Blood cultures : Positive in 40–90%

depending on the organismdepending on the organism

Lumbar punctureLumbar puncture

Gold standard for establishing Gold standard for establishing diagnosis- diagnosis- isolation of bacteria from isolation of bacteria from CSFCSF

Do LP once stablisedDo LP once stablised If LP delayed and bacterial meningitis If LP delayed and bacterial meningitis

is clinically suspected , antibiotics is clinically suspected , antibiotics should be given prior to LP should be given prior to LP

Indications to delay LPIndications to delay LP

Indications of CT prior to LPIndications of CT prior to LP Signs of ↑ICT (e.g. papilloedema )Signs of ↑ICT (e.g. papilloedema ) Suspecting malignancy( focal Suspecting malignancy( focal

neurological deficits)neurological deficits) Deteriorating neurological statusDeteriorating neurological status Previous neurosurgical procedure or Previous neurosurgical procedure or

traumatrauma Immunocompromised Immunocompromised

Normal CT scan does not exclude the risk Normal CT scan does not exclude the risk of raised ICTof raised ICT

Interpreting CSFInterpreting CSF

No single CSF parameter distinguishes No single CSF parameter distinguishes bacterial from non bacterial meningitisbacterial from non bacterial meningitis

< 3% instances CSF normal< 3% instances CSF normal When clinical indicators of meningitisWhen clinical indicators of meningitis

are present but initial CSF examinationare present but initial CSF examination

is normal - repeat LP at 24-48 hoursis normal - repeat LP at 24-48 hours

may be indicatedmay be indicated

Typical CSF findingsTypical CSF findings

CSF parameter

Normal Bacterial meningitis

Viral meningitis

PMN 0 100-10000 <100

Mononuclear cells

< 5 (<20 in neonates)

<100 10-1000

Protein (g/L) < 0.4 >1 0.4 - 1

Glucose (mmol/L)

<2.5 Usually decreased

Usually normal

Glucose ( CSF : Blood ratio)

> 0.6 <0.4 Usually normal

GRAM STAIN GRAM STAIN Best single test for rapid diagnosis of Best single test for rapid diagnosis of

bacterial meningitisbacterial meningitis Sensitivity- 60- 90%Sensitivity- 60- 90% Specificity- > 97%Specificity- > 97% positive Gram stain – bacterial count positive Gram stain – bacterial count

> 1×103 cells per mL in CSF> 1×103 cells per mL in CSF Positive in 90% pneumococcal, 86% Positive in 90% pneumococcal, 86%

Hib, 75% meningococcal, 50% gram Hib, 75% meningococcal, 50% gram neg and 33% listeria meningitisneg and 33% listeria meningitis

Interpretation of traumatic Interpretation of traumatic CSFCSF

1WBC : 500 RBC is acceptable; but 1WBC : 500 RBC is acceptable; but dependant on peripheral countsdependant on peripheral counts

Protein levels may be elevatedProtein levels may be elevated 0.01- 0.015 g/L increase in protein 0.01- 0.015 g/L increase in protein

levels for every 1000 RBC ‘ s in levels for every 1000 RBC ‘ s in uncentrifuged CSFuncentrifuged CSF

  Peripheral WBC/RBC count× CSF RBC count = Peripheral WBC/RBC count× CSF RBC count =

CSF WBC countCSF WBC count

Interpretation of CSF in Interpretation of CSF in those with prior use of those with prior use of

antibioticsantibiotics rate of positive CSF culture and Gram rate of positive CSF culture and Gram

stain recovery decreases stain recovery decreases Complete sterilisation within 2 hr in Complete sterilisation within 2 hr in

N.meningitidis and within 4 hr in N.meningitidis and within 4 hr in pneumococcal meningitispneumococcal meningitis**

Cell count and biochemistry are not Cell count and biochemistry are not significantly influencedsignificantly influenced

Kanegaye JT et al. Pediatrics 2001Kanegaye JT et al. Pediatrics 2001

what investigations help in early what investigations help in early diagnosisdiagnosis??

Latex agglutinationLatex agglutination commercially available antisera directed commercially available antisera directed

against the capsular polysaccharides of against the capsular polysaccharides of meningeal pathogensmeningeal pathogens

Rapid results <15 minRapid results <15 min a positive CSF antigen test result did not a positive CSF antigen test result did not

affect clinical therapy or hospital courseaffect clinical therapy or hospital course** Culture negative meningitis, CSF latex Culture negative meningitis, CSF latex

agglutination had a sensitivity of only 7% in agglutination had a sensitivity of only 7% in one studyone study##

*Maxson et al. J Pediatr.1994*Maxson et al. J Pediatr.1994

#Tarafdar k et al.clin Infect Dis.2001#Tarafdar k et al.clin Infect Dis.2001

may be most useful for the patient may be most useful for the patient who has been pretreated with who has been pretreated with antimicrobial therapy and whose antimicrobial therapy and whose Gram stain and CSF culture results Gram stain and CSF culture results are negative are negative (B-III)(B-III)

Limulus lysate assayLimulus lysate assay positive test result suggests the positive test result suggests the

presence of endotoxin presence of endotoxin detect ∼103 gram-negative bacteria/mL detect ∼103 gram-negative bacteria/mL

of CSF and as little as 0.1 ng/mL of of CSF and as little as 0.1 ng/mL of endotoxinendotoxin

negative test does not rule out negative test does not rule out diagnosis of gram neg meningitis & diagnosis of gram neg meningitis & results rarely influence patient treatmentresults rarely influence patient treatment

Not routinely recommended Not routinely recommended (D II)(D II)

PCRPCR amplify DNA amplify DNA Broad based PCR - sensitivity 100%, a Broad based PCR - sensitivity 100%, a

specificity 98.2%, PPV 98.2%, and NPV specificity 98.2%, PPV 98.2%, and NPV 100%100%**

Appears to be promising for etiological Appears to be promising for etiological diagnosisdiagnosis

May be useful in gram stain negative May be useful in gram stain negative meningitis meningitis (B II)(B II)

*Saravolatz LD et al.Clin Infect Dis 2003*Saravolatz LD et al.Clin Infect Dis 2003

What Laboratory Testing What Laboratory Testing May Be Helpful in Distinguishing May Be Helpful in Distinguishing Bacterial from Viral Meningitis ?Bacterial from Viral Meningitis ?

Determination of lactate Determination of lactate concentrationconcentration

Generally non specific ; despite high Generally non specific ; despite high sensitivity and PPVsensitivity and PPV

CSF lactate was found to be superior to CSF lactate was found to be superior to CSF :blood glucose in postoperative CSF :blood glucose in postoperative neurosurgical patientsneurosurgical patients**

CSF concentration of 4.0 mmol/ L was CSF concentration of 4.0 mmol/ L was used as a cutoff value for the diagnosisused as a cutoff value for the diagnosis

*Leib SL et al.Clin Infect Dis. 1999*Leib SL et al.Clin Infect Dis. 1999

Determination of C-reactive protein Determination of C-reactive protein (CRP) concentration(CRP) concentration

Sensitivity - 18% to 100%, and specificity Sensitivity - 18% to 100%, and specificity

75% to 100%75% to 100%**in differentiating bacterial and in differentiating bacterial and viral meningitisviral meningitis

Sen -96%, spe 93%, NPV-99% in Sen -96%, spe 93%, NPV-99% in distinguishing gram negative meningitisdistinguishing gram negative meningitis

normal CRP has a high negative predictivenormal CRP has a high negative predictive

value in the diagnosis of bacterial meningitis value in the diagnosis of bacterial meningitis (BII)(BII)

*Gerdes at al.Scan J Clin Lab*Gerdes at al.Scan J Clin Lab

Determination of procalcitonin Determination of procalcitonin concentrationconcentration

Sensitivity 94%, specificity- 100% Sensitivity 94%, specificity- 100% using cut off >5mcg/L using cut off >5mcg/L **

Not routinely available. so no Not routinely available. so no recommendations as of nowrecommendations as of now

*Gendrel et al.Clin Infect Dis.1997*Gendrel et al.Clin Infect Dis.1997

How Quickly Should How Quickly Should Antimicrobial Therapy Be Antimicrobial Therapy Be Administered to Patients with Administered to Patients with Suspected Bacterial Meningitis?Suspected Bacterial Meningitis?

As soon as bacterial meningitis As soon as bacterial meningitis is is

suspected suspected

If LP delayed and bacterial If LP delayed and bacterial meningitis is clinically suspected , meningitis is clinically suspected , antibiotics should be given prior to LP antibiotics should be given prior to LP

Retrospective study –outcome based on Retrospective study –outcome based on nature of presentationnature of presentation

nonspecific illness nonspecific illness - a short delay (3–5 days) - a short delay (3–5 days) did not appear to alter the risk of sequelae did not appear to alter the risk of sequelae or deathor death

fulminant meningitisfulminant meningitis-delay in the initiation -delay in the initiation of antibiotics seemed to be unconnected to of antibiotics seemed to be unconnected to outcomeoutcome

clinically overt meningitis - clinically overt meningitis - inappropriate inappropriate delay incrementally increased the risk of delay incrementally increased the risk of permanent injurypermanent injury

Radetsky et al.Pediatr Infect Dis J.1992Radetsky et al.Pediatr Infect Dis J.1992

What Specific Antimicrobial What Specific Antimicrobial Agents Should Be Used in Agents Should Be Used in Patients with Suspected or Patients with Suspected or Proven Bacterial Meningitis?Proven Bacterial Meningitis?

Appropriate empirical regimen Appropriate empirical regimen i.e one that covers resistant i.e one that covers resistant S.pneumoniae , N.meningitidis and S.pneumoniae , N.meningitidis and H.influenza B- H.influenza B-

Third generation cephalosporin + Third generation cephalosporin + vancomycin vancomycin

IDSA guidelines. 2004IDSA guidelines. 2004

   NIMHANS study: NIMHANS study:

Streptococcus pneumoniae Streptococcus pneumoniae remains remains the major aetiological agent of CAABMthe major aetiological agent of CAABM

No penicillin resistance was detected No penicillin resistance was detected among the isolatesamong the isolates

R mani et al.Indian J Med Microbiol.2007R mani et al.Indian J Med Microbiol.2007

Third generation Third generation cephalosporinscephalosporins

drugs of choice for empirical therapy drugs of choice for empirical therapy for for H. influenzae meningitisH. influenzae meningitis

recommended in pneumococcal and recommended in pneumococcal and meningococcal meningitis caused by meningococcal meningitis caused by strains that are not susceptible to strains that are not susceptible to penicillin penicillin (AIII)(AIII)

Cefepime also has greater in vitroCefepime also has greater in vitro

activity than the third-generation activity than the third-generation cephalosporins against cephalosporins against EnterobacterEnterobacter

species and species and Pseudomonas Pseudomonas aeruginosaaeruginosa**

Kaplan SL.Clin Infect Dis J.Kaplan SL.Clin Infect Dis J.

VancomycinVancomycin

Even in patients with meningitis caused Even in patients with meningitis caused by highly penicillin and cephalosporin by highly penicillin and cephalosporin resistant strains, vancomycin should be resistant strains, vancomycin should be combined with a thirdgeneration combined with a thirdgeneration cephalosporin cephalosporin (A-III) (A-III) and should not be and should not be used as a single agentused as a single agent

Kaplan SL.Clin Microbio RevKaplan SL.Clin Microbio Rev

Meropenam Meropenam

Broad in vitrio activityBroad in vitrio activity Useful as alternative to third Useful as alternative to third

generation cephalosporin generation cephalosporin (AIII)(AIII) Useful in gram negative meningitis Useful in gram negative meningitis

resistant to standard therapyresistant to standard therapy**

Buckingham SC.South Med J.2002Buckingham SC.South Med J.2002

Rifampin Rifampin

Good CSF penetration and in vitrio activityGood CSF penetration and in vitrio activity Resistance develops rapidly when used Resistance develops rapidly when used

alonealone combine with a third-generation combine with a third-generation

cephalosporin +/- vancomycin, cephalosporin +/- vancomycin, pneumococcal meningitis caused by pneumococcal meningitis caused by highly penicillin- or cephalosporin highly penicillin- or cephalosporin resistant strainsresistant strains**

Kaplan SL.Pedr Infect Dis J.2002Kaplan SL.Pedr Infect Dis J.2002

What Is the Role of Adjunctive What Is the Role of Adjunctive Dexamethasone Therapy in Dexamethasone Therapy in Patients with Bacterial Patients with Bacterial Meningitis?Meningitis?

RationaleRationale subarachnoid space inflammatory subarachnoid space inflammatory

response - major factor contributing response - major factor contributing to morbidity and mortalityto morbidity and mortality

Attenuation of this inflammatory Attenuation of this inflammatory response- decrease cerebral edema, response- decrease cerebral edema, increased ICP, altered cerebral blood increased ICP, altered cerebral blood flow, cerebral vasculitis, and flow, cerebral vasculitis, and neuronal injury, as mediated by neuronal injury, as mediated by proinflammatory cytokine expressionproinflammatory cytokine expression

Hib meningitis - Hib meningitis - reduced hearing reduced hearing impairment overall ; whereas inimpairment overall ; whereas in

pneumococcal meningitis - only pneumococcal meningitis - only suggested protection for severe suggested protection for severe hearing loss if given earlyhearing loss if given early**

2007 Cochrane review2007 Cochrane review- lower case - lower case mortality, and lower rates of severe mortality, and lower rates of severe hearing loss and long-term hearing loss and long-term neurological sequelaeneurological sequelae

*McIntyre PB et al.meta analysis. JAMA*McIntyre PB et al.meta analysis. JAMA

Committee on Infectious Diseases of Committee on Infectious Diseases of the AAP the AAP ::

““For infants and children 6 weeks of age For infants and children 6 weeks of age and older, adjunctive therapy with and older, adjunctive therapy with dexamethasone may be considered dexamethasone may be considered after weighing the potential benefits after weighing the potential benefits and possible risks. Experts vary in and possible risks. Experts vary in recommending the use of recommending the use of corticosteroids in pneumococcal corticosteroids in pneumococcal meningitis; data are not sufficient to meningitis; data are not sufficient to demonstrate clear benefit in children “demonstrate clear benefit in children “

Recommendation Recommendation

Steroids are recommended Steroids are recommended early in early in children ≥3 months of age just children ≥3 months of age just before or at the time of antibioticsbefore or at the time of antibiotics, , provided that they have not been provided that they have not been pre-treated with parenteral pre-treated with parenteral antibioticsantibiotics

dosing regimen is dosing regimen is 0.15 mg/kg/dose 0.15 mg/kg/dose IV, every 6 hours for 2-4 daysIV, every 6 hours for 2-4 days

Management of Raised ICP in Management of Raised ICP in meningitis meningitis

General measuresGeneral measures Head end elevation 15–30°Head end elevation 15–30° Maintenance fluids – isotonic fluids to Maintenance fluids – isotonic fluids to

maintain MAP ; if this fails vasopressors maintain MAP ; if this fails vasopressors can be initiatedcan be initiated

Agressively treat fever- antipyretics/ Agressively treat fever- antipyretics/ cooling blanketscooling blankets

Adequate sedation and analgesiaAdequate sedation and analgesia Maintain euvolemia/euglycemiaMaintain euvolemia/euglycemia Prevention and treatment of seizuresPrevention and treatment of seizures

Specific measuresSpecific measures

Mannitol: Initial bolus: 0.25–1 g/kg, Mannitol: Initial bolus: 0.25–1 g/kg, then 0.25–0.5 g/kg, q 2–6 h as per then 0.25–0.5 g/kg, q 2–6 h as per requirement, up to 48 hrsrequirement, up to 48 hrs

Hypertonic Saline: Preferable in Hypertonic Saline: Preferable in presence of Hypotension, Hypovolemia, presence of Hypotension, Hypovolemia, Serum osmolality >320 mOsm/kg, Serum osmolality >320 mOsm/kg, Renal failure, Dose: 0.1–1 ml/kg/hr Renal failure, Dose: 0.1–1 ml/kg/hr infusion, Target Na+−145–155 meq/Linfusion, Target Na+−145–155 meq/L

Mannitol vs hypertonic Mannitol vs hypertonic salinesaline

Recent meta analysis: Recent meta analysis: Evidence is Evidence is non-definitive regarding any non-definitive regarding any advantages to treating ICP with advantages to treating ICP with hypertonic saline over Mannitolhypertonic saline over Mannitol

Kamel H et al. Crit care Med 2011Kamel H et al. Crit care Med 2011..

HyperventilationHyperventilation — Target PaCo2  — Target PaCo2 30-35 mmHg ( reserved for episodes 30-35 mmHg ( reserved for episodes of acute brain herniation or ICP of acute brain herniation or ICP elevation )elevation )

Refractory raised ICP- hypothermia, Refractory raised ICP- hypothermia, barbiturate coma, decompressive barbiturate coma, decompressive craniectomycraniectomy

what is the duration of what is the duration of antimicrobial therapy based on antimicrobial therapy based on isolated pathogenisolated pathogen??

Organism Duration of therapy (days)

Group B streptococcus 14

Gram negative rods 21

Listeria monocytogenes 21

Neiserria meningitidis 7

Hemophilus influenza 7-10

Streptococcus pneumoniae 14

Culture negative meningitis 7

What Are the Indications What Are the Indications for Repeated Lumbar Puncture in for Repeated Lumbar Puncture in Patients with Bacterial Patients with Bacterial Meningitis?Meningitis?

any patient who has not responded any patient who has not responded clinically after 48 h of appropriate clinically after 48 h of appropriate antimicrobial therapy antimicrobial therapy

In neonates with gram negative In neonates with gram negative

meningitis to document sterilisationmeningitis to document sterilisation

Prognostic factors?Prognostic factors?

  GCS- independent predictor of death or GCS- independent predictor of death or neurological sequeleneurological sequele

EtiologyEtiology Mortality and neurologic sequelae are Mortality and neurologic sequelae are

higher with pneumococcal meningitis higher with pneumococcal meningitis Hearing loss -30 % in pneumococcal Hearing loss -30 % in pneumococcal

meningitis, 10 % in meningococcal meningitis, 10 % in meningococcal meningitis, and 5-20 % in Hib meningitismeningitis, and 5-20 % in Hib meningitis**

Nelson textbook of pediatricsNelson textbook of pediatrics

CSF glucose concentration (<20mg/ CSF glucose concentration (<20mg/ dL ) – associated with hearing lossdL ) – associated with hearing loss

Time to sterilization of CSF after Time to sterilization of CSF after start of therapy (16 to 18 hours after start of therapy (16 to 18 hours after the initiation of therapy)the initiation of therapy)

Malnutrition :increased morbidity and Malnutrition :increased morbidity and mortalitymortality

Seizures > 72 hours after initiation of Seizures > 72 hours after initiation of appropriate antimicrobial therapy -appropriate antimicrobial therapy -increased risk of neurologic sequelae increased risk of neurologic sequelae 

Follow up?Follow up?

Neurological sequele in Neurological sequele in survivorssurvivors

Hearing /visual deficitHearing /visual deficit Seizure disorderSeizure disorder Cranial nerve palsyCranial nerve palsy ParesisParesis Cognitive impairmentCognitive impairment hydrocephalushydrocephalus

Hearing assessment should be Hearing assessment should be done at dischage or within 6-8 wks done at dischage or within 6-8 wks by PTA/BERA. If normal then by PTA/BERA. If normal then reassessed at 3months, 6 months reassessed at 3months, 6 months and 1 yrand 1 yr

severe sequele not discovered at severe sequele not discovered at discharge do not appear laterdischarge do not appear later

Children who appear well have more Children who appear well have more non-specific symptoms like headache, non-specific symptoms like headache, and inattention, hyperactivity and and inattention, hyperactivity and impulsiveness than their siblingsimpulsiveness than their siblings

Berq et al.Eur J Ped.2002Berq et al.Eur J Ped.2002

Preventive measures?Preventive measures?

Immunisation Immunisation

Immunisation is the most effective Immunisation is the most effective means of prevention BM in childrenmeans of prevention BM in children

IAP recommends routine use of Hib IAP recommends routine use of Hib vaccine in children vaccine in children with efficacy rate with efficacy rate against invasive infection ranges from 70-against invasive infection ranges from 70-100%100%

IAP recommends IAP recommends pnemococcal and pnemococcal and meningococcal vaccination for high risk meningococcal vaccination for high risk childrenchildren as vaccines under special as vaccines under special circumstances.circumstances.

Meningococcal vaccineMeningococcal vaccine

MCV-4 (A,C, Y, W-135)MCV-4 (A,C, Y, W-135) Minimal age- 2 yrsMinimal age- 2 yrs Revaccination only once after 3yrs Revaccination only once after 3yrs

in those at continued high riskin those at continued high risk

Pneumococcal vaccinePneumococcal vaccine

Minimum age - 6wks for Minimum age - 6wks for pnemococcal conjugate vaccine(PCV) pnemococcal conjugate vaccine(PCV) and 2yrs for polysaccharide and 2yrs for polysaccharide vaccine(PPSV)vaccine(PPSV)

PCV must be offered to premature PCV must be offered to premature and low birth weight infantsand low birth weight infants

Functional/anatomic asplenia and Functional/anatomic asplenia and immunodeficient individuals- high immunodeficient individuals- high riskrisk

Chemoprophylaxis Chemoprophylaxis --to household contacts to household contacts

Neiserria meningitidis Rifampin 10mg/kg/dose q12h for 2 days

H.influenza Rifampin 20mg/kg/24 hr for 4 days

Thank youThank you